Multilayered Amniotic Membrane
`Transplantation for Severe Ulceration of the
`Cornea and Sclera
`
`KAZUOMI HANADA, MD, JUN SHIMAZAKI, MD, SHIGETO SHIMMURA, MD, AND
`KAZUO TSUBOTA, MD
`
`c PURPOSE: To examine the efficacy of amniotic mem-
`brane transplantation in the treatment of deep corneal
`and scleral ulcers.
`c PATIENTS: A total of 11 patients were recruited for
`this study: four patients (four eyes) with corneal perfo-
`ration, five patients (five eyes) with a deep corneal ulcer
`and descemetocele, and two patients (two eyes) with a
`scleral ulcer.
`c METHODS: Ulcers were treated by amniotic membrane
`transplantation. Separate amniotic membranes were
`transplanted as material to fill the stromal layer (amniotic
`membrane filling), as a basement membrane (amniotic
`membrane graft), and as a wound cover (amniotic mem-
`brane patch). After surgery, all cases were treated with
`artificial tears, autologous serum drops, antibiotic eye-
`drops, topical corticosteroids, and sodium hyaluronate
`eyedrops.
`c RESULTS: Eight eyes (72.7%) healed with epithelial-
`ization in 16.5 6 8.0 days (range, 7 to 29 days), with five
`and three eyes showing corneal epithelialization and
`conjunctival epithelialization, respectively. A persistent
`epithelial defect was noted in one eye with corneal ulcer
`after limbal allograft transplantation for a chemical burn
`and in two eyes with corneal ulcers as a complication of
`rheumatoid arthritis.
`c CONCLUSION: Multilayered amniotic membrane trans-
`plantation may be effective for the treatment of deep
`ulceration of the cornea and sclera. In some eyes with
`total corneal limbal dysfunction or autoimmune disor-
`ders, amniotic membrane transplantation alone is not
`effective.
`(Am J Ophthalmol 2001;131:324 –331.
`© 2001 by Elsevier Science Inc. All rights reserved.)
`
`Accepted for publication Sep 22, 2000.
`From the Department of Ophthalmology, Tokyo Dental College,
`Chiba, Japan.
`Reprint requests to Kazuomi Hanada, MD, Department of Ophthal-
`mology, Asahikawa Medical College, 2-1 Midorigaoka Higashi, Asa-
`hikawa-shi Hokkaido, 078-8510, Japan;
`fax: 81-166-68-2549; e-mail:
`hanada@asahikawa-med.ac.jp
`
`D ESPITE THE MANY MEDICAL AND SURGICAL AP-
`
`proaches that have been developed to treat them,
`ulcers of the cornea and sclera are still major
`problems. Ulceration induced by persistent epithelial de-
`fects is often resistant to medical or surgical treatment.
`When the basement membrane and stromal matrix are
`damaged, normal wound healing processes cannot proceed,
`and other factors, such as persistent inflammation, may
`also compromise wound healing. Treatment of ulceration
`induced by persistent epithelial defects requires that a
`healthy basement membrane be provided and that inflam-
`mation be reduced to promote epithelialization.
`Amniotic membrane has long been used as a surgical
`material for ophthalmic surgery. De Ro¨tth first reported
`the use of amniotic membrane in conjunctival plastic
`surgery in 1940,1 but it has not appeared again in the
`literature until recently. The current popularity of using
`amniotic membrane started when Kim and Tseng reintro-
`duced the procedure in 1995.2 Amniotic membrane has a
`number of indications, both as a graft to replace damaged
`ocular surface stroma matrix3–5 and as a patch to decrease
`inflammation.6 In the present series, we used amniotic
`membrane to treat severe ulcers secondary to persistent
`epithelial defects.
`
`SUBJECTS AND METHODS
`
`ELEVEN PATIENTS (11 EYES; SIX MEN AND FIVE WOMEN;
`mean age, 63.5 6 13.1 years) with severe ulceration of the
`cornea or sclera were treated by amniotic membrane
`transplantation (Table 1). Four eyes had corneal perfora-
`tion, five eyes had deep corneal ulcers with descemetocele,
`and two eyes had scleral ulcers. All eyes had been treated
`with eyedrops and/or a therapeutic soft contact lens
`without success. All operations were performed after ob-
`taining informed consent.
`Three of 11 patients also had dry eye. To assess tear
`dynamics, the Schirmer value without anesthesia and the
`tear clearance rate were measured 5 minutes after instilling
`
`324
`
`© 2001 BY ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED.
`
`0002-9394/01/$20.00
`PII S0002-9394(00)00825-4
`
`

`

`allo-LT5allograftlimbaltransplantation;AMgraft5amnioticmembranegraft;CL5therapeuticsoftcontactlens;LKP5lamellarkeratoplasty;MMC5mitomycinCusedintraoperatively;
`
`PKP5penetratingkeratoplasty;RA5rheumatoidarthritis;SJS5Stevens-Johnsonsyndrome;Ts5tarsorraphy.
`
`cataract
`Glaucoma,
`
`Foreignbody
`
`F
`
`58
`
`11
`
`Cataract
`
`Pterygium
`
`M
`
`Cornea
`
`Cornea
`
`Cornea
`Cornea
`
`Cornea
`
`RA,postLKP
`
`Leukoma
`
`RA,postLKP
`
`Glaucoma
`
`SJS,postLT
`
`Glaucoma
`Glaucoma
`
`Moorenulcer
`Bullouskeratopathy
`
`Glaucoma
`
`Chemicalburn
`
`keratopathy
`
`Cornea
`
`Leukoma,band
`
`Trichiasis
`
`Cornea
`
`Cornea
`
`Foreignbody
`
`Foreignbody
`
`M
`
`M
`
`F
`
`M
`
`F
`
`M
`
`M
`
`F
`
`F
`
`75
`
`67
`
`54
`
`54
`
`74
`81
`
`48
`
`79
`
`47
`
`56
`
`10
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`Cornea/Sclera
`
`Complications
`
`UnderlyingDisease
`
`Sex
`
`Other
`
`(years)
`
`Age
`
`Case
`
`VOL. 131, NO. 3
`
`MULTILAYERED AMNIOTIC MEMBRANE TRANSPLANTATION FOR SEVERE ULCER
`
`325
`
`No
`
`No
`
`cover,Ts
`Conjunctival
`
`Miroperforation
`
`633
`
`Sclera
`
`No
`
`No
`
`No
`
`Yes
`
`No
`No
`
`Yes
`
`No
`
`No
`
`No
`
`No
`
`No
`
`No
`
`Yes
`
`No
`No
`
`Yes
`
`Yes
`
`No
`
`No
`
`andcyclosporin
`
`Systemicsteroid
`
`andcyclosporin
`
`Systemicsteroid
`
`andcyclosporin
`
`Systemicsteroid
`
`andcyclosporin
`
`Systemicsteroid
`CL
`
`andcyclosporin
`
`Systemicsteroid
`
`adhesive,Ts
`
`CL,surgical
`adhesive
`CL,surgical
`adhesive
`CL,surgical
`
`Dysfunction
`TotalLimbal
`
`Condition
`DryEye
`
`PriorTreatment
`
`Surgery
`Previous
`
`(MMC)
`excision
`pterygium
`
`Microperforation
`
`LKP
`
`Descemetocele
`
`LKP
`
`Descemetocele
`
`graft1Ts
`Allo-LT1AM
`
`PKP
`
`graft1Ts
`Allo-LT1AM
`
`Descemetocele
`
`Descemetocele
`Descemetocele
`
`Rupture
`
`Microperforation
`
`Microperforation
`
`Microperforation
`
`Condition
`
`232
`
`636
`
`636
`
`434
`
`632
`535
`
`534
`
`633
`
`333
`
`333
`
`(mm)
`
`Sclera
`
`Cornea
`
`SizeofUlcer
`
`TABLE1.PatientProfile
`
`

`

`a 10-ml drop of fluorescein 0.5% and oxybuprocaine
`hydrochloride 0.4% into the conjunctival sac. Patients
`with a Schirmer value with anesthesia of under 10 mm per
`5 minutes or a product of the Schirmer value times the tear
`clearance rate (tear function index) of under 34 were
`diagnosed with dry eye.7 The Schirmer value and tear
`clearance rate were not measured in the perforated cases,
`and dry eye was assessed in the other eye. Limbal function
`was assessed on the basis of the presence of palisades of
`Vogt, vascular invasion of the cornea, and severe conjunc-
`tivalization of the cornea. Impression cytology was per-
`formed in limbal deficiency cases
`to detect
`signs of
`conjunctivalization.8
`After written consent was obtained, amniotic mem-
`brane was obtained during cesarean section in women
`sero-negative for hepatitis B virus, hepatitis C virus,
`syphilis, and human immunodeficiency virus. The amni-
`otic membrane with underlying chorion was washed in
`0.01 mol/l phosphate-buffered saline containing 1 mg/ml
`of dibekacin sulfate (Panimycin; Meiji Pharmaceutical
`Company, Tokyo, Japan) and bluntly separated from the
`placenta. The membrane was then cut into approximately
`3 3 3 cm pieces and rinsed in 0.01 mol/l phosphate-
`buffered saline. Each segment was rinsed in 0.5 mol/l
`dimethyl sulfoxide dissolved in phosphate-buffered saline
`and then in 1.0 mol/l and 1.5 mol/l dimethyl sulfoxide in
`phosphate-buffered saline for 5 minutes each. The mem-
`brane was placed in a small container filled with 1.5 mol/l
`dimethyl sulfoxide in phosphate-buffered saline and pre-
`served at 280°C until used. All procedures were performed
`under sterile conditions. Preoperatively, the container
`with amniotic membrane was thawed at room temperature,
`and the membrane was rinsed three times in saline and
`then once in saline containing 1 mg/ml of dibekacin
`sulfate. The amniotic membrane was separated bluntly
`from the underlying chorion with forceps during surgery.
`Surgery was performed under subconjunctival or sub-
`tenon’s capsule anesthesia with lidocaine 2% containing
`1:8 3 104 noradrenaline (Xylocaine E; Fujisawa Pharma-
`ceutical Company, Osaka, Japan). First, the bottom of the
`ulcer was debrided, and poorly attached epithelium at the
`edge of the ulcer was removed as bluntly as possible. After
`the ulcer surface was treated and healthy corneal or scleral
`stroma was exposed, the first segment of amniotic mem-
`brane was transplanted as filling material in the stromal
`layer (amniotic membrane filling). The amniotic mem-
`brane was cut into small pieces and stuffed into the ulcer.
`In the scleral ulcer cases, the ulcer was filled with auto-
`tenon’s capsule tissue. The second amniotic membrane was
`transplanted as a basement membrane (amniotic mem-
`brane graft). Amniotic membrane was placed on the ulcer
`with epithelial side up and secured with 10 – 0 nylon
`sutures. The third amniotic membrane was transplanted as
`a cover (amniotic membrane patch) with 10 – 0 nylon or
`8 – 0 vicryl sutures. The amniotic membrane patch was
`placed on the entire wound and corneal
`limbus with
`
`FIGURE 1. Surgical steps in multilayered amniotic membrane
`transplantation. (Top) The first amniotic membrane is cut into
`small pieces and pushed into the ulcer (arrows). The second
`amniotic membrane is placed on the ulcer with epithelial side up
`and secured with 10 – 0 nylon sutures. (Middle) The third
`amniotic membrane is transplanted as a cover with epithelial
`side up (arrows). (Bottom) Surgical schema. Note the amniotic
`membrane pushed into the ulcer as a filling material in the
`stromal layer (amniotic membrane filling), placed on ulcer with
`epithelial side up as a basement membrane (amniotic membrane
`graft), and on the entire wound with epithelial side up as a
`cover (amniotic membrane patch).
`
`epithelial side up to protect the area of re-epithelialization
`(Figure 1).
`Postoperatively, antibiotic eyedrops, corticosteroid eye-
`drops, and sodium hyaluronate eyedrops were instilled. In
`eyes without dry eye, ofloxacin 0.3% eyedrops (Tarivid;
`Santen Pharmaceutical Company, Osaka, Japan), dexa-
`
`326
`
`AMERICAN JOURNAL OF OPHTHALMOLOGY
`
`MARCH 2001
`
`

`

`TABLE 2. Amniotic Membrane Transplantation Results
`
`Case
`
`Follow-up
`(weeks)
`
`Preoperative
`BCVA
`
`Postoperative
`BCVA
`
`Epithelialized
`With
`
`Epithelialization
`(days)
`
`Complications
`(weeks)
`
`Other Treatment,
`Final BCVA
`
`1
`2
`
`3
`4
`
`5
`6
`7
`8
`
`9
`10
`11
`
`60
`22
`
`64
`43
`
`36
`32
`46
`37
`
`40
`50
`28
`
`20/200
`20/100
`
`20/40
`20/20
`
`LP1
`LP1
`
`LP2
`LP2
`LP2
`HM
`
`HM
`LP1
`
`LP2
`LP2
`LP2
`HM
`
`Cornea
`Cornea
`
`Cornea
`
`Cornea
`Cornea
`Conjunctiva
`
`HM
`20/100
`20/2000
`
`HM
`20/100
`20/2000
`
`Conjunctiva
`Conjunctiva
`
`7
`16
`
`18
`(failed)
`
`29
`15
`10
`(failed)
`
`(failed)
`10
`27
`
`Hypopion (4)
`
`PED (5)
`
`Frequent use of
`antibiotics, 20/
`20
`
`Auto-conjunctival
`patching, LP1
`
`PED (13)
`
`PED (20)
`
`PKP1ECCE1IOL,
`20/200
`PKP, 20/40
`
`BCVA 5 best-corrected visual acuity; ECCE1IOL 5 extracapsular cataract extraction and intraocular lens implantation; HM 5 hand
`motions; LP 5 light perception; PED 5 persistent epithelial defect.
`
`methasone 0.1% eyedrops (Sanbetasone; Santen Pharma-
`ceutical Company),
`and sodium hyaluronate 0.1%
`eyedrops (Hyalein 0.1; Santen Pharmaceutical Company)
`were instilled five times a day. In the dry eye cases, all
`eyedrops were preservative free and included ofloxacin
`0.3% eyedrops (Tarivid), methylprednisolone 1% eyedrops
`(made from Solu-medrol; Pharmacia and Upjohn, Tokyo,
`Japan), and sodium hyaluronate 0.1% eyedrops (Hyalein-
`Mini 0.1; Santen Pharmaceutical Company) instilled five
`times a day. During the same period, autologous serum
`drops9 and artificial tears (Soft-santear; Santen Pharma-
`ceutical Company) were instilled 10 times a day.
`
`RESULTS
`
`EIGHT EYES (72.7%) HEALED WITH EPITHELIALIZATION IN
`16.5 6 8.0 days (range, 7 to 29 days; Table 2). Three of the
`eyes with corneal perforation (cases 1 to 3) and two eyes
`with descemetocele (cases 5 and 6) exhibited corneal
`epithelialization. One eye with descemetocele (case 7),
`caused by persistent epithelial defects after limbal allograft
`transplantation for Stevens-Johnson syndrome, developed
`conjunctivalization because of poor corneal limbal func-
`tion. Both eyes with scleral ulcer (cases 10 and 11) were
`successfully epithelialized by conjunctiva. Improvement in
`best-corrected visual acuity was acquired in three eyes
`(cases 1 to 3). In cases 4 to 11, visual acuity was not
`changed postoperatively.
`Amniotic membrane transplantation failed in three eyes
`(27.3%). Case 4, in which there was a large perforation
`after allograft transplantation for a chemical burn, developed
`
`persistent epithelial defects that did not respond to medical
`treatment and simple amniotic membrane patch. The patient
`had poor limbal
`function with severe dry eye and was
`eventually treated with a conjunctival patch. Two other eyes
`(cases 8 and 9) with rheumatoid arthritis-related peripheral
`corneal ulcers also developed persistent epithelial defects.
`Despite intensive medical therapy and immunosuppression
`with systemic cyclosporin and corticosteroids, these cases
`required penetrating keratoplasty. Infection was suspected in
`one eye. In case 2, inflammation was observed in the anterior
`chamber 4 weeks after surgery. Topical amikacin sulfate 0.5%
`(Amikacin; Banyu Pharmaceutical Company, Tokyo, Japan),
`vancomycin hydrochloride 2.5% (Vancomycin; Shionogi
`Pharmaceutical Company, Osaka Japan), sulbenicillin so-
`dium 1% (Sulperin; Senju Pharmaceutical Company, Osaka,
`Japan), and cefmenoxime hemihidrochloride 0.5% (Bestron;
`Senju Pharmaceutical Company) were used 10 times a day.
`The inflammation resolved after 5 days (Table 2).
`
`CASE REPORTS
`
`c CASE 1: A 56-year-old man was treated by an ophthalmol-
`ogist for an iron foreign body in his right eye in March 1998.
`One month after removal of the foreign body, an ulcer still
`persisted and perforation occurred, and the patient was
`referred to our clinic on April 28, 1998. The initial exami-
`nation revealed a corrected visual acuity in the right eye of
`20/200. The cornea was perforated, aqueous humor was
`leaking, and there was iris herniation (Figure 2, top left). We
`applied surgical adhesive glue and a therapeutic soft contact
`lens for a month, but the ulcer did not heal. Multilayered
`
`VOL. 131, NO. 3
`
`MULTILAYERED AMNIOTIC MEMBRANE TRANSPLANTATION FOR SEVERE ULCER
`
`327
`
`

`

`FIGURE 2. (Top left) Preoperative appearance of case 1. The cornea is perforated, aqueous humor is leaking, and the iris is
`herniated. (Top right) Seven days postoperatively, total epithelialization is obtained and there is no leakage of aqueous humor. Sixty
`weeks after surgery, the amniotic membrane filling remains in the stroma. The amniotic membrane graft is functioning as a basement
`membrane, while maintaining transparency. (Middle left) Case 5. Descemetocele is seen preoperatively. (Middle right) Twenty-nine
`days after surgery, corneal surface is totally epithelialized, and corneal thickness is restored. (Bottom left) Case 6. An ulcer with
`persistent epithelial defect is seen at the corneal margin preoperatively. (Bottom right) Fifteen days after surgery, corneal surface
`is totally epithelialized.
`
`amniotic membrane transplantation was performed on May
`29, 1998, and the corneal surface totally epithelialized within
`7 days. The sutures in the amniotic membrane graft were
`removed after 1 month, at which time there was no leakage
`of the aqueous humor and intraocular pressure was normal.
`
`At 60 weeks after surgery, corrected visual acuity in the right
`eye was 20/40. The amniotic membrane filling remained in
`the stroma, and the amniotic membrane graft functioned as a
`basement membrane, while maintaining semitransparency
`(Figure 2, top right).
`
`328
`
`AMERICAN JOURNAL OF OPHTHALMOLOGY
`
`MARCH 2001
`
`

`

`c CASE 5: An 81-year-old woman was treated for chemi-
`cal injury of the cornea with penetrating keratoplasty on
`her right eye in 1992. Four years after penetrating kerato-
`plasty, the graft underwent endothelial rejection, and
`bullous keratopathy with persistent epithelial defects oc-
`curred. The patient had no light perception in her right
`eye because of glaucoma. Medical treatment consisting of
`ofloxacin 0.3% eyedrops, methyl-prednisolone 1% eye-
`drops, and hyaluronate sodium 0.1% eyedrops five times a
`day with autologous serum drops 10 times a day was
`started. However, the cornea thinned, and the persistent
`epithelial defects eventually developed a desmetocele (Fig-
`ure 2, middle left). Multilayered amniotic membrane
`transplantation was performed on August 19, 1998.
`Within 29 days after surgery, the corneal surface had
`totally epithelialized, and corneal thickness was restored
`(Figure 2, middle right). Persistent epithelial defects have
`not recurred to date.
`
`c CASE 6: A 75-year-old man had corneal peripheral
`ulcers in both eyes in February 1998. He was referred to our
`clinic 1 week later with a diagnosis of bilateral Mooren
`ulcer, at which time the ulceration had expanded from the
`margin to the center of the cornea. The patient also had
`primary open-angle glaucoma and cataracts in both eyes.
`He had undergone trabeculectomy in both eyes 10 years
`earlier. The initial examination revealed a corrected visual
`acuity in his right eye of 20/2000, and his left eye had no
`light perception. He was initially treated medically with
`ofloxacin 0.3% eyedrops, methylprednisolone 1% eye-
`drops, and hyaluronate sodium 0.1% eyedrops, five times a
`day, and autologous serum drops 10 times a day. During the
`same period, we prescribed oral cyclosporin 5 mg/kg
`(Sandimmun; Novaris Pharma Company, Tokyo, Japan).
`After 6 months, the ulceration in the right eye showed
`corneal epithelialization, but the left eye had not healed.
`The corneal ulcer persisted with corneal opacity and ciliary
`injection (Figure 2, bottom left), and on October 15, 1998,
`multilayered amniotic membrane transplantation was per-
`formed to prevent corneal perforation. Within 10 days
`after surgery, the corneal surface had totally epithelialized,
`the inflammation was suppressed (Figure 2, bottom right),
`and the patient was relieved of pain.
`
`DISCUSSION
`
`PREVIOUS REPORTS HAVE DEMONSTRATED THAT THE AM-
`niotic membrane has unique properties, including antibac-
`terial, wound-protecting, pain-reducing, epithelialization-
`promoting, and fibrosis-suppressing effects.10 –14 These
`properties are considered suitable for the treatment of
`impaired epithelialization of the ocular surface. Lee and
`Tseng6 used amniotic membrane for the treatment of
`persistent epithelial defects, and the results showed the
`efficacy of amniotic membrane patch. Improvement of
`
`epithelialization may be attributed to inhibition of colla-
`genase by amniotic membrane, and supplementation of the
`basement membrane and growth factors. In addition to
`taking advantage of these properties in the present study,
`amniotic membrane was also used to supplement the
`collagen layer. A combination of collagen layer supple-
`mentation, basement membrane reconstruction, and pro-
`motion of epithelialization and wound healing is required
`to treat severe ulceration. We used multilayered amniotic
`membrane transplantation to achieve these goals. Amni-
`otic membrane filling provides a substitute for collagens,
`the amniotic membrane graft provides basement mem-
`brane for proper epithelializaton, and the amniotic mem-
`brane patch protects the wound. Kruse and associates15
`reported the efficacy of amniotic membrane graft for deep
`corneal ulcer to supply stromal layer. We found that eight
`of 11 eyes (72.7%) were successfully treated by this method
`with a mean epithelialization period of 16.5 6 8.0 days.
`Leakage of aqueous humor was cured in five eyes, and the
`corneal/scleral stroma regained its original thickness. No
`recurrence of persistent epithelial defects was observed in
`the mean follow-up period of 42.3 6 15.2 weeks. These
`results suggested that if signs of infection are negative,
`amniotic membrane can be used not only to treat corneal
`ulcers, but corneal and scleral perforation as well.
`The failed cases of amniotic membrane transplantation,
`there are total limbal deficiency or autoimmune disorders.
`The basement membrane side of the amniotic membrane is
`an ideal substrate for supporting the growth of epithelial
`progenitor cells by prolonging their life span and main-
`taining their clonogenicity.16 Amniotic membrane trans-
`plantation can be used to expand remaining limbal stem
`cells and corneal transient amplifying cells during the
`treatment of partial
`limbal deficiency.17 However, this
`specific action is not effective when there are no stem cells,
`and then healthy limbal function may be needed.18 In
`cases of limbal deficiency, amniotic membrane transplan-
`tation may be a useful adjunct when performed at the time
`of limbal stem cell transplantation. Ulceration resulting
`from autoimmune disease has to be treated carefully as
`well. Although one case of Mooren ulcer was successfully
`treated, two eyes with rheumatoid arthritis-related corneal
`ulcer developed persistent epithelial defects postopera-
`tively. The existence of irreversible damage on the cornea
`was suggested, and these two cases were finally treated with
`penetrating keratoplasty and underwent intensive immu-
`nosupression. A primary immunologic disturbance with
`production of autoantibodies against conjunctival and
`corneal tissue may be the reason for this, and control of the
`immunologic imbalance should precede in these condi-
`tions.
`Conservative management, such as continuous pressure
`patching with ointment, heals most cases of corneal
`epithelial defects. However, cases with persistent epithelial
`defects require more extensive procedures. Medical ther-
`apy with preservative-free lubricants as the most suitable
`
`VOL. 131, NO. 3
`
`MULTILAYERED AMNIOTIC MEMBRANE TRANSPLANTATION FOR SEVERE ULCER
`
`329
`
`

`

`agents is the treatment of first choice. Topical corticoste-
`roids may be chosen to reduce inflammation, but they
`should be used carefully. The continuous use of a thera-
`peutic soft contact lens promotes the healing of epithelial
`defects.19 In cases that do not respond to a medical
`approach, a surgical procedure is required.
`Tarsorraphy is the first surgical technique to maintain
`the moisture of the ocular surface to treat epithelial defects
`induced by a dry eye or inadequate blinking condition.20
`The efficacy of tarsorraphy is limited to the assistance of
`corneal wound healing. Prolonged, severe ocular surface
`disorders require more extensive treatment. Surgical adhe-
`sive glue is sometimes used to fill small corneal perfora-
`tions,21 but it cannot replace the total thickness of the
`corneal stroma or sclera. The effect of adhesion is not
`permanent, and it sometimes delays normal wound healing
`and epithelialization. In the past, conjunctival transplan-
`tation or conjunctival cover was frequently used in an
`emergency, but it can cause neovascularization, fibrosis,
`and proliferation of abnormal epithelium. Inflammation
`and invading vessels caused by conjunctival tissue may be
`a risk factor in further treatment, such as penetrating
`keratoplasty or other ocular surface reconstructions.
`A donor cornea may be the most suitable material for
`grafting to treat a damaged cornea. Penetrating kerato-
`plasty and lamellar keratoplasty are commonly used to
`treat corneal ulceration,22 but both require donor tissue. In
`emergencies, it is sometimes too late by the time a donor
`is found, especially in Japan, where the donor cornea
`supply is small. There is also the risk of rejection after
`surgery because of the donor cornea’s immunogenicity.
`Ulceration often induces persistent epithelial defects or
`persistent inflammation, which may increase the risk of
`graft failure.
`In case 2, inflammation was observed in the anterior
`chamber 4 weeks after surgery, but it resolved after 5 days
`in response to frequent use of antibiotic eyedrops. The
`amniotic membrane was preserved in clean condition, and
`all amniotic membrane cultured at operation use was
`negative. Organisms cultured were negative. However,
`microbial keratitis was suspected. To prevent postoperative
`infection and achieve epithelialization, it is important to
`debride the bottom of the ulcer and poorly attached
`epithelium at the edge of the ulcer. Amniotic membrane
`transplantation should also be avoided in cases with active
`infection. A cornea totally covered with amniotic mem-
`brane makes observation of the anterior chamber or fundus
`difficult. Because of its lack of transparency, there is the
`risk of overlooking signs of infections or inflammation.
`In summary, we found that multilayered amniotic mem-
`brane transplantation may be effective for the treatment of
`deep ulceration of the cornea and sclera. The unique
`characteristics of amniotic membrane appear to offer a new
`surgical approach to ocular surface diseases. In some eyes
`with total corneal
`limbal dysfunction or autoimmune
`
`disorders, amniotic membrane transplantation alone is not
`effective. We recognize that cases with total limbal dys-
`function or autoimmune disorder are not cured by amni-
`otic membrane transplantation alone. Our series is based
`on the excellent ideas of predecessors. However, the entire
`mechanism of the healing effect of amniotic membrane is
`still unknown. Further studies are needed to understand
`the mechanisms involved in the benefits of amniotic
`membrane on the ocular surface.
`
`REFERENCES
`
`1. de Ro¨tth A. Plastic repair of conjunctival defects with fetal
`membranes. Arch Ophthalmol 1940;23:522–525.
`2. Kim JC, Tseng SCG. Transplantation of preserved human
`amniotic membrane for surface reconstruction in severely
`damaged rabbit corneas. Cornea 1995;14:472– 484.
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`tion of the ocular surface in advanced ocular cicatricial
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`mol 1996;122:38 –52.
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`thalmol 1997;123:303–312.
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`measure of dry eye. Arch Ophthalmol 1995;233:1–7.
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`corneal diseases with limbal stem cell deficiency. Ophthal-
`mology 1995;102:1476 –1485.
`9. Tsubota K, Goto E, Fujita H, et al. Treatment of dry eye by
`autologous serum application in Sjo¨gren’s syndrome. Br J
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`10. Trelford JD, Trelford-Sauder M. The amnion in surgery, past
`and present. Am J Obstet Gynecol 1979;134:833– 845.
`11. Colocho G, Graham WP, Greene AE, et al. Human amni-
`otic membrane as a physiologic wound dressing. Arch Surg
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`13. Subrahmanyam M. Amniotic membrane as a cover for
`microskin grafts. Br J Plast Surg 1995;48:477– 478.
`14. Talmi YP, Finckelstein Y, Zohar Y. Use of human amniotic
`membrane as a biologic dressing. Eur J Plast Surg 1990;13:
`160 –162.
`15. Kruse FE, Rohrschneider K, Vo¨lcker HE. Multilayer amni-
`otic membrane transplantation for reconstruction of deep
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`16. Meller D, Tseng SCG. Conjunctival epithelial cell differen-
`tiation on amniotic membrane. Invest Ophthalmol Vis Sci
`1999;40:878 – 886.
`17. Tseng SCG, Prabhasawat P, Barton K, et al. Amniotic
`membrane transplantation with or without limbal allografts
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`330
`
`AMERICAN JOURNAL OF OPHTHALMOLOGY
`
`MARCH 2001
`
`

`

`for corneal surface reconstruction in patients with limbal
`stem cell deficiency. Arch Ophthalmol 1998;116:431– 441.
`18. Tsubota K, Satake Y, Kaido M, et al. Treatment of severe
`ocular surface disorders with corneal epithelial stem-cell
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`treatment of persistent corneal lesions. Acta Ophthalmol
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`21. Boruchoff SA, Refojo M, Slansky HH, et al. Clinical
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`The full-text of AJO is now available online at www.ajo.com. Authors
`Interactivet, currently available in limited form, is undergoing an upgrade.
`
`VOL. 131, NO. 3
`
`MULTILAYERED AMNIOTIC MEMBRANE TRANSPLANTATION FOR SEVERE ULCER
`
`331
`
`

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